Expresión tisular de los componentes del sistema fibrinolítico y de las metaloproteasas en la endometriosis.

RESUMEN La endometriosis es una enfermedad ginecológica caracterizada por la presencia de tejido endometrial fuera del útero. Se trata de una enfermedad muy prevalente en mujeres con dolor pélvico o esterilidad. Aunque la endometriosis es una enfermedad benigna, el tejido endometrial adquiere la capacidad de adherirse e invadir el peritoneo, produciéndose un proceso de proteolisis de la matriz extracelular (MEC). En este proceso están íntimamente implicados el sistema fibrinolítico y el de las metaloproteasas de la matriz extracelular (MMPs). El sistema fibrinolítico se basa en la conversión del plasminógeno en plasmina por la acción de dos enzimas, el activador tisular del plasminógeno (tPA) y el activador del plasminógeno de tipo uroquinasa (uPA). A esta tendencia profibrinolítica se opone una actividad antifibrinolítica, mediada por tres inhibidores de los activadores del plasminógeno (PAI-1, PAI-2, PAI-3). La plasmina y sus activadores tienen una importante función proteolítica tisular interviniendo en procesos de proliferación y adhesión celular. Las MMPs son una familia de enzimas zinc-dependientes capaces de degradar los componentes de la MEC. Junto con los inhibidores de las MMPs o TIMPs, forman un sistema que controla el correcto recambio del tejido conectivo y puede alterarse en condiciones patológicas como es el caso del cáncer o la endometriosis. El presente estudio analiza diversos componentes del sistema fibrinolítico y de las metaloproteasas en muestras de tejido proveniente de 55 pacientes con endometriosis y 37 mujeres controles. Se ha estudiado por ELISA los niveles antigénicos de los activadores fibrinolíticos y sus inhibidores, así como la MMP-3 y el TIMP-1, en el endometrio y el líquido peritoneal de ambos grupos y en el tejido proveniente del endometrioma ovárico de las pacientes con endometriosis. Además, se ha determinado los niveles funcionales de tPA, uPA y PAI-1. Además, se ha estudiado mediante inmunohistoquimia la expresión de uPA, PAI-1 y PAI-3 y mediante hibridación in situ la expresión de mRNA de PAI-1. Existe un aumento del nivel de uPA y MMP-3 en el endometrio de mujeres con endometriosis y un aumento de PAI-1 y TIMP-1 en el endometrioma ovárico con una disminución de PAI-3 en este tejido. El análisis de las muestras pareadas confirmó estos resultados. El líquido peritoneal muestra un aumento de uPA antigénica en los estadios avanzados de la enfermedad, no encontrándose diferencias en función de la recidiva de la enfermedad. La inmunohistoquimia mostró una señal de uPA mayor en el endometrio de la mujer con endometriosis localizada tanto a nivel glandular como en el estroma. El PAI-1 se expresó con intensidad en el endometrioma ovárico, a nivel del epitelio, el estroma y el endotelio vascular. La señal de PAI-3 en el endometrioma fue de moderada intensidad y de localización estromal. Por otra parte, la hibridación in situ mostró una expresión de PAI-1 débil en el endometrio de la mujer con endometriosis y los controles e intensa en el endometrioma. Nuestros resultados nos permiten especular en la secuencia de acontecimientos que llevaría a la implantación y la formación del quiste endometriósico. El aumento inicial de la actividad enzimática observada en el endometrio de mujeres con endometriosis estaría mediada por uPA y MMP-3. Este hecho aumentaría la adhesión del tejido endometrial a la superficie ovárica y peritoneal, así como facilitar la invasión de la matriz extracelular. Este proceso desencadenaría la formación de la lesión endometriósica inicial. Una vez formado el quiste endometriósico ovárico se produce un aumento de los niveles de inhibidores (PAI-1 y TIMP-1), sin detectarse un aumento en la actividad proteolítica. La razón por la cual esta actividad proteolítica se limita a los estadios iniciales de la enfermedad es todavía desconocida, pero este comportamiento podría explicar la formación del quiste endometriósico sin invasión del tejido ovárico circundante. ____________________________________________________________________________________________________Endometriosis is defined by the presence of endometrial glands and stroma outside the uterus. It is a disease that affects up to 60% of women with pelvic pain and infertility. The etiology and pathogenesis of endometriosis are far from clear, despite several decades of research in this field. Although endometriosis is a benign disease, the endometrial tissue acquires the ability to attach and invade the peritoneum where a local extracellular proteolysis might take place. This process involves the plasminogen activator (PA) and matrix metalloproteinase (MMP) systems. The aim of this study is to analyse several components of the plasminogen activator (PA) pathway and the matrix metalloproteinase (MMP) system in endometriotic tissue, endometrium and peritoneal fluid from women with and without endometriosis (controls). 55 women with endometriosis and 37 controls were studied. In endometrium of women with endometriosis the antigenic levels of urokinase type-PA (uPA) and MMP-3 were elevated compared to endometrium from controls. Ovarian endometriotic tissues had higher antigenic levels of PA inhibitor type 1 (PAI-1) and MMP inhibitor type 1 (TIMP-1) than endometrium. The peritoneal fluid from women with endometriosis showed an increase in uPA levels. No differences were observed according to the presence of recurrence of the disease. Immunohystochemistry showed higher uPA expression in endometrium of women with endometriosis. PAI-1 was highly expressed in ovarian endometrioma stroma and endothelium. In situ hybridization showed an intense expression of PAI-1 mRNA in ovarian endometrioma. We conclude that the high levels of uPA and MMP-3 in endometrium of women with endometriosis might contribute to the invasive potential of endometrial cells. Once the ovarian endometriotic cyst is developed, high PAI-1 and TIMP-1 levels are detected and significant proteolytic activity is no longer observed. The increase of inhibitors and the reduction in proteolytic activity could explain the frequent clinical finding of isolated endometriotic cyst without invasion of the surrounding ovarian tissue

Comparison of Peritoneal Carcinomatosis Scoring Methods in Predicting Resectability and Prognosis in Gynecologic Malignancies

Objective: Peritoneal carcinomatosis is a disease’s presentation in the advanced stages of many gynecologic tumours. The distribution and volume of the disease are the main factors in achieving complete debulking. Diagnostic laparoscopy is a technique to allow evaluation of the disease. This study’s objective is to compare two laparoscopic scores (Fagotti’s index and Sugarbaker’s peritoneal cancer index (PCI)) and assess the diagnostic accuracy to select patients for neoadjuvant treatment and reduce unnecessary laparotomies. Methods: A non-randomised retrospective cohort study was conducted in patients with peritoneal carcinomatosis (ovarian and endometrial origin) who underwent laparoscopy and subsequent laparotomy. We evaluated the scores’ ability to predict incomplete surgery and whether they were related to the patients’ prognosis. Results: We included 34 patients, of which 23.5% received neoadjuvant chemotherapy. The rate of complete cytoreductive surgery was 79.4% (n = 27 patients). The highest sensitivity was obtained with a PCI value greater than 20. It was the best parameter to determine incomplete debulking. Survival curves were analysed according to the “cut off” established for each score, and statically significant differences were found using PCI with respect to Fagotti’s Index. However, these differences were not found with Fagotti’s score. Conclusion: The best diagnostic method to classify patients with peritoneal cancer is the PCI. It could be adapted to each surgical team because it allows identifying the “cut off point”, which depends on incomplete surgery rate

Interplay Between MicroRNAs and Oxidative Stress in Ovarian Conditions with a Focus on Ovarian Cancer and Endometriosis.

Ovarian cancer and endometriosis are two distinct gynaecological conditions that share many biological aspects incuding proliferation, invasion of surrounding tissue, inflammation, inhibition of apoptosis, deregulation of angiogenesis and the ability to spread at a distance. miRNAs are small non-coding RNAs (19-22 nt) that act as post-transcriptional modulators of gene expression and are involved in several of the aforementioned processes. In addition, a growing body of evidence supports the contribution of oxidative stress (OS) to these gynaecological diseases: increased peritoneal OS due to the decomposition of retrograde menstruation blood facilitates both endometriotic lesion development and fallopian tube malignant transformation leading to high-grade serous ovarian cancer (HGSOC). Furthermore, as HGSOC develops, increased OS levels are associated with chemoresistance. Finally, continued bleeding within ovarian endometrioma raises OS levels and contributes to the development of endometriosis-associated ovarian cancer (EAOC). Therefore, this review aims to address the need for a better understanding of the dialogue between miRNAs and oxidative stress in the pathophysiology of ovarian conditions: endometriosis, EAOC and HGSO

Peritonitis primaria por streptococcus pyogenes, infección inusual en mujeres jóvenes.

ANTECEDENTES: la peritonitis primaria es una entidad poco frecuente que se observa en pacientes con patología crónica. Sin embargo, cuando es causada por Streptococcus pyogenes la población más afectada son mujeres jóvenes sin antecedentes médicos, pudiendo derivar en un cuadro más grave, por ejemplo sepsis. CASO CLÍNICO: paciente de 30 años de edad que consulta por dolor abdominal severo acompañado de fiebre, con signos de irritación peritoneal y dolor a la movilización cervical. Las pruebas de imagen mostraban signos inespecíficos, sin imágenes sugerentes de perforación. Ante el cuadro de abdomen agudo se realizó una laparoscopia exploradora. El único hallazgo fue la gran cantidad de líquido purulento, que se remitió a estudio microbiológico. Horas después, la paciente tuvo un deterioro progresivo, con hipotensión, taquicardia, taquipnea, y oliguria. Los parámetros infecciosos se incrementaron y se alteró la coagulación. Debido al cuadro de sepsis se ingresó a la unidad de cuidados intensivos. En el cultivo de cérvix, orina, líquido peritoneal y en hemocultivos se aisló S. pyogenes. Se diagnosticó: peritonitis primaria por S. pyogenes con sepsis secundaria y fue tratada con antibióticos de amplio espectro. CONCLUSIÓN: ante un cuadro de peritonitis en una mujer joven sin comorbilidad y con pruebas de imagen sin hallazgos, debe sospecharse peritonitis primaria causada por S. pyogenes. El diagnóstico es difícil y normalmente se realizan varias pruebas de imagen e incluso intervenciones quirúrgicas para intentar establecer un diagnóstico certero

Peritoneal carcinomatosis index as a predictor of diaphragmatic involvement in stage III and IV ovarian cancer.

Objective: To analyze the surgical outcomes and diaphragmatic involvement in stage III and IV ovarian cancer. Patients and methods: All patients with stage III-IV ovarian cancer between January 2013 and January 2016 were included. The outcomes of interest reviewed were as follows: surgical (complications, mortality), peritoneal carcinomatosis index (PCI), rate of complete resection, and disease-free interval and survival. Results: Fifty-seven patients were included, 38 (67%) with diaphragmatic involvement; in 10 cases (18%), diaphragmatic resection was required. Optimal cytoreduction (OCR) was obtained in 49 cases (86%). The PCI was 10 in 31 cases (54%). Respiratory complications occurred in 10 cases (18%) and mortality in 3 (5%). Disease-free survival rate in 3 years was 53%, being 87% in cases without diaphragmatic involvement. The overall survival rate in 3 years is 46%, 83% in the cases without diaphragmatic involvement and 27% in cases with affectation (p 0.05). In cases of OCR, 3 year survival rate was 65%. In the multivariate analysis for the overall survival of cases with OCR, the only independent prognostic factor found was the operative PCI. A strong correlation was found between the total PCI and the diaphragmatic PCI (p 0.001). With a PCI 10, virtually all cases will present diaphragmatic involvement (p 0.05). Conclusion: The tumor burden is different in stages III and IV of advanced ovarian cancer and the PCI is an effective method to quantify it. The PCI constitutes an independent prognostic factor for the advanced stages of ovarian cancer. A PCI 10 constitutes a useful prognostic factor of the affectation and forces the surgeon to thoroughly review both diaphragms

Postoperative intestinal fistula in primary advanced ovarian cancer surgery

Background: Advanced ovarian cancer (AOC) requires an aggressive surgery with large visceral resections in order to achieve an optimal or complete cytoreduction and increase the patient’s survival. However, the surgical aggressiveness in the treatment of AOC is not exempt from major complications, such as the gastrointestinal fistula (GIF), which stands out among others due to its high morbidity and mortality. Methods: We evaluated the clinicopathological features in patients with AOC and their association with GI. Data for 107 patients with AOC who underwent primary debulking surgery were analyzed retrospectively. Clinicopathological features, including demographic, surgical procedures and follow-up data, were analyzed in relation to GIF. Results: GIF was present in 11% of patients in the study, 5 (4.5%) and 7 (6.4%) of colorectal and small bowel origin, respectively. GIF was significantly associated with peritoneal cancer index (PCI) > 20, more than 2 visceral resections, and multiple digestive resections. Overall and disease-free survival were also associated with GIF. Multivariate analysis identified partial bowel obstruction and operative bleeding as independent prognostic factors for survival. The presence of GIF is positively associated with poor prognosis in patients with AOC. Conclusion: Given the importance of successful cytoreductive surgery in AOC, the assessment of the amount of tumor and the aggressiveness of the surgery to avoid the occurrence of GIF become a priority in patients with AOC

Increased levels of NETosis biomarkers in high-grade serous ovarian cancer patients’ biofluids: Potential role in disease diagnosis and management

Introduction: High-grade serous ovarian cancer (HGSOC) is the second most frequent gynecological malignancy but the most lethal, partially due to the spread of the disease through the peritoneal cavity. Recent evidence has shown that, apart from their role in immune defense through phagocytosis and degranulation, neutrophils are able to participate in cancer progression through the release of neutrophil extracellular traps (NETs) in a process called NETosis. NETs are composed of DNA, histones, calprotectin, myeloperoxidase (MPO) and elastase and the NETosis process has been proposed as a pre-requisite for the establishment of omental metastases in early stages of HGSOC. Nevertheless, its role in advanced stages remains to be elucidated. Therefore, our principal aim is to characterize a NETosis biomarker profile in biofluids from patients with advanced HGSOC and control women. Methods: Specifically, five biomarkers of NETosis (cell-free DNA (cfDNA), nucleosomes, citrullinated histone 3 (citH3), calprotectin and MPO) were quantified in plasma and peritoneal fluid (PF) samples from patients (n=45) and control women (n=40). Results: Our results showed that HGSOC patients presented a higher concentration of cfDNA, citH3 and calprotectin in plasma and of all five NETosis biomarkers in PF than control women. Moreover, these biomarkers showed a strong ability to differentiate the two clinical groups. Interestingly, neoadjuvant treatment (NT) seemed to reduce NETosis biomarkers mainly systemically (plasma) compared to the tumor environment (PF). Discussion: In conclusion, NETosis biomarkers are present in the tumor environment of patients with advanced HGSOC, which might contribute to the progression of the disease. Besides, plasma cfDNA and calprotectin could represent minimally invasive surrogate biomarkers for HGSOC. Finally, NT modifies NETosis biomarkers levels mainly at the systemic level

Neoadjuvant Chemotherapy plus Interval Cytoreductive Surgery with or without Hyperthermic Intraperitoneal Chemotherapy (NIHIPEC) in the Treatment of Advanced Ovarian Cancer: A Multicentric Propensity Score Study

Simple Summary Advanced ovarian cancer (Stages III-IV) continues to be one of the gynecological tumors with the highest mortality. Standard treatment consists of debulking surgery and subsequent adjuvant chemotherapy. Recently, some authors have postulated that the administration of hyperthermic chemotherapy during surgery could increase the survival of patients, especially in cases in which chemotherapy had already been administered before surgery to reduce tumor volume. Our study is important because it collects data from 11 tertiary hospitals in Spain, and the data are subjected to a statistical technique that reproduces the data that we would find in a prospective study but using retrospective data (propensity score matching). It also offers a current view of the status of ovarian cancer treatment in our country.Abstract Introduction: Epithelial ovarian cancer (EOC) is primarily confined to the peritoneal cavity. When primary complete surgery is not possible, neoadjuvant chemotherapy (NACT) is provided; however, the peritoneum-plasma barrier hinders the drug effect. The intraperitoneal administration of chemotherapy could eliminate residual microscopic peritoneal tumor cells and increase this effect by hyperthermia. Intraperitoneal hyperthermic chemotherapy (HIPEC) after interval cytoreductive surgery could improve outcomes in terms of disease-free survival (DFS) and overall survival (OS). Materials and Methods: A multicenter, retrospective observational study of advanced EOC patients who underwent interval cytoreductive surgery alone (CRSnoH) or interval cytoreductive surgery plus HIPEC (CRSH) was carried out in Spain between 07/2012 and 12/2021. A total of 515 patients were selected. Progression-free survival (PFS) and OS analyses were performed. The series of patients who underwent CRSH or CRSnoH was balanced regarding the risk factors using a statistical analysis technique called propensity score matching. Results: A total of 170 patients were included in each subgroup. The complete surgery rate was similar in both groups (79.4% vs. 84.7%). The median PFS times were 16 and 13 months in the CRSH and CRSnoH groups, respectively (Hazard ratio (HR) 0.74; 95% CI, 0.58-0.94; p = 0.031). The median OS times were 56 and 50 months in the CRSH and CRSnoH groups, respectively (HR, 0.88; 95% CI, 0.64-1.20; p = 0.44). There was no increase in complications in the CRSH group. Conclusion: The addition of HIPEC after interval cytoreductive surgery is safe and increases DFS in advanced EOC patients

Peritoneal fluid reduces angiogenesis-related microRNA expression in cell cultures of endometrial and endometriotic tissues from women with endometriosis.

UNLABELLED: Endometriosis, defined as the presence of endometrium outside the uterus, is one of the most frequent gynecological diseases. It has been suggested that modifications of both endometrial and peritoneal factors could be implicated in this disease. Endometriosis is a multifactorial disease in which angiogenesis and proteolysis are dysregulated. MicroRNAs (miRNAs) are small non-coding RNAs that regulate the protein expression and may be the main regulators of angiogenesis. Our hypothesis is that peritoneal fluid from women with endometriosis could modify the expression of several miRNAs that regulate angiogenesis and proteolysis in the endometriosis development. The objective of this study has been to evaluate the influence of endometriotic peritoneal fluid on the expression of six miRNAs related to angiogenesis, as well as several angiogenic and proteolytic factors in endometrial and endometriotic cell cultures from women with endometriosis compared with women without endometriosis. METHODS: Endometrial and endometriotic cells were cultured and treated with endometriotic and control peritoneal fluid pools. We have studied the expression of six miRNAs (miR-16, -17-5p, -20a, -125a, -221, and -222) by RT-PCR and protein and mRNA levels of vascular endothelial growth factor-A, thrombospondin-1, urokinase plasminogen activator and plasminogen activator inhibitor-1 by ELISA and qRT-PCR respectively. RESULTS: Control and endometriotic peritoneal fluid pools induced a significant reduction of all miRNAs levels in endometrial and endometriotic cell cultures. Moreover, both peritoneal fluids induced a significant increase in VEGF-A, uPA and PAI-1 protein levels in all cell cultures without significant increase in mRNA levels. Endometrial cell cultures from patients treated with endometriotic peritoneal fluid showed lower expression of miRNAs and higher expression of VEGF-A protein levels than cultures from controls. In conclusion , this "in vitro" study indicates that peritoneal fluid from women with endometriosis modulates the expression of miRNAs that could contribute to the angiogenic and proteolytic disequilibrium observed in this disease